Auditing in ISO 15189 - Society for Quality in Health Care...
-
Upload
doankhuong -
Category
Documents
-
view
220 -
download
3
Transcript of Auditing in ISO 15189 - Society for Quality in Health Care...
![Page 1: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/1.jpg)
Auditing in ISO 15189
F.A. M-Segotta PathCare
![Page 2: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/2.jpg)
What does ISO 15189 say?
• The quality system must undergo internal and
external audits.
• ISO 15189 specifically requires annual internal audits.
• The purpose audits is to verify that the laboratory is in compliance with the quality system.
• Internal audit findings must be documented to develop a plan to correct
• Again, documenting actions taken creates a quality record.
![Page 3: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/3.jpg)
Different types of audits
• Internal Audits
• Intra Organization Audits
• External Audits
![Page 4: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/4.jpg)
Internal / Intra Organization
Audits
• Focus will be on Internal / Intra Organization Audits
• Only performed by competent and trained personnel
• Important Nigerian Context – no body
![Page 5: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/5.jpg)
The Quality Management System
Model
![Page 6: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/6.jpg)
Intended use of Internal
Audits
• Directors
• Managers
• Supervisors
• Applicable to laboratories of all sizes
![Page 7: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/7.jpg)
Benefits of Laboratory Internal Audit Program
• There are many… to name a few
• The benefits of conducting internal audits are of astronomical value to any medical laboratory
• Regularly scheduled internal audits of the laboratory’s QMS move a laboratory from a mode of reactive-corrective action to that of proactive, continual improvement.
• The improvements made through internal audits are directly tied to quality planning, performance.
![Page 8: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/8.jpg)
Keys to a successful Internal
Audit Program
• Commitment by leadership
• Collective desire to improve quality
• Understanding audit is an ongoing process
• Compressive planning and resource allocation
• Must have trained & knowledgeable staff
![Page 9: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/9.jpg)
Types of audits
System Audit
Process Audit
Product or Service Audit
• The audit is further divided into retrospective and prospective types.
• A retrospective audit captures information on outcomes that have occurred in the past,
• Whereas a prospective audit captures information in real time.
![Page 10: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/10.jpg)
How audit is conducted…
• How the audit is conducted is further divided into retrospective and prospective types.
• A retrospective audit captures information on outcomes that have occurred in the past,
• Whereas a prospective audit captures information in real time.
• Retrospective audits require reviews of selected records
• Whereas prospective audits use direct observation.
![Page 11: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/11.jpg)
Practical Methods of audits as
described in ISO 15189
• Traditionally audits finds non-conformities… Fed Up – un constructive…
• Look – what might go wrong
• … used to find potential non-conformities or opportunities for improvement
• Pathologists…62, 63, 64
4 Management requirements 4.14 Evaluation and audits
![Page 12: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/12.jpg)
Practical Methods of audits as
described in ISO 15189
• Horizontal – Contaminated Blood tubes
• Vertical – Vein to Brain
• Witness – Employee competence
4 Management requirements 4.14 Evaluation and audits
![Page 13: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/13.jpg)
Audit schedule
• Types…
• Annual Scheduled Audits
• Ideally scheduled:
Reduce stress / Elicit staff cooperation
• Unscheduled Audits
Not ideal, only if
• Serious complaint, breach of confidentially
![Page 14: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/14.jpg)
Example…
0
10
20
30
40
50
60
70
2006 2007 2008 2009 2010 2011 2012
Internal NC's
Internal Company NC's
External NC's
Total NC's
![Page 15: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/15.jpg)
Conclusion
The value of internal audits can not be overstated.
Internal audits is the glue that bonds the whole quality management system together
………and ultimately ensures Quality in each and every process.
![Page 16: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/16.jpg)
•In the PathCare Internal Audit team…
• … there is a slogan we use…
![Page 17: Auditing in ISO 15189 - Society for Quality in Health Care …sqhn.org/.../2013/10/Wim-Medic-West-Africa-Audits.pdf•ISO 15189 specifically requires annual internal audits. •The](https://reader034.fdocuments.net/reader034/viewer/2022051508/5abe45887f8b9a8e3f8ccdcf/html5/thumbnails/17.jpg)